CHAPTER FOUR: FIRST DAY ON ADMISSION AND SECOND DAY ON ADMISSION

By | July 14, 2021

FIRST DAY ON ADMISSION (8TH NOVEMBER, 2019)

Patient did not sleep well during the night. She was assisted to perform hygiene activities such as, bathing and grooming and brushing of her teeth after.

On ward rounds with the Doctor at 8:30am, client complained of epigastric pain and loss of appetite. She was reassured of getting well again. The Doctor requested that she should continue with her previous treatment. She was put in the supine position to reduce muscle spasm and tension and also prescribed analgesics were administered. She was involved in her meal planning to ensure that her favourite foods are prepared.

She had little knowledge about her condition and was thus educated. The condition was explained to her in simple words that could help her to understand the causes, signs and symptoms, medical and surgical treatment in addition to some preventive measures, as well as the complications. She was encouraged to ask questions and also asked to give a verbal account of what she has been taught. Questions which were asked were answered accordingly and she gave accurate feedback on what she had been taught. Lunch was served around 1:00pm.

Vital signs checked throughout the day were within the following ranges;

Temperature                           –    36.5-37.0 Degree Celsius

Pulse                                       –     72-84 beats per minute

Respiration                              –     20-24 cycle per minute

Blood Pressure                        –      110/70-120/80 millilitres of mercury

Other general nursing duties such as feeding and drug administration were performed and documented in the nurses’ note.

 

CHAPTER FOUR: FIRST DAY ON ADMISSION AND SECOND DAY ON ADMISSION

SECOND DAY ON ADMISSION (9TH NOVEMBER, 2019)

Patient woke up at 5:30am and was assisted in carrying out her daily activities of personal hygiene such as bathing and caring for her mouth. She was made comfortable in bed after her linen and her clothing had been changed. All her prescribed medications were served. She complained that she was not able to sleep. She was reassured that it was due to change of environment and that she will be fine.

During ward rounds, she was reviewed and put on additional treatment of Intravenous Fluid (IVF) Ringers Lactate 1 litre. The intravenous infusion was collected from the pharmacy and was administered as prescribed by the Doctor. Patient was made comfortable in bed after the ward rounds and a quiet atmosphere was also ensured to allow patient have enough sleep. Lunch was served at 1:30pm.

Vital signs checked within the day were within the ranges of;

Temperature                       –      36.3-36.5 Degree Celsius

Pulse                                   –      76-80 beats per minute

Respiration                          –      20-22 cycle per minute

Blood Pressure                     –      120/80-130/80 millilitres of mercury

THIRD DAY ON ADMISSION (10TH NOVEMBER, 2019)

Patient’s condition had improved considerably well. She slept quiet well. In the morning she woke up very early to take care of her personal hygiene, a warm bath and mouth care to improve appetite. Vital signs were checked and recorded and medications were also served. Patient’s breakfast was served afterwards.

On ward rounds, she complained of constipation. She was encouraged to take in lots of fluids especially water every day. She was encouraged to do moderate exercises such as walking around the ward and also take in roughages together with her meals. The Doctor asked her to continue her treatment. There were no further complaints. She was served with rice and kontomire stew and fruit juice as dessert. Her appetite had improved as she ate greater portion of the food that was served. Her medications were administered and documented. Vital signs checked within was between the ranges of:

Temperature                       –      36.2-36.9 Degree Celsius

Pulse                                   –      76-80 beats per minute

Respiration                          –      20-22 cycle per minute

Blood Pressure                     –      120/80-130/80 millilitres of mercury

FOURTH DAY ON ADMISSION (11TH NOVEMBER, 2019)

Client woke up early and carried out her daily hygiene activities such as bathing and caring for the mouth.

During ward rounds in the morning she had no complains and the Doctor said the condition had improved after doing some observations on her. The Doctor requested that she should continue with her treatment.

In the afternoon, she was served with her lunch. Her medications were also administered and documented.

Her relatives were informed of the intension to visit their home when her relatives visited her during the visiting hours. In the evening, she was served with supper around 5:00pm. Medications were also served and documented. She was encouraged to have a warm bath to induce sleep. Nearby windows were also opened to allow fresh air into the ward to facilitate sleep.

Vital signs checked within the day ranged as follows:

Temperature                       –      36.4-36.5 Degree Celsius

Pulse                                   –      76-80 beats per minute

Respiration                          –      21-22 cycle per minute

Blood Pressure                     –      120/70-130/80 millilitres of mercury

 

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